Kevin R. Campbell, MD: "First of all, we must consider the morbidity and mortality associated with disorders requiring anticoagulation. In atrial fibrillation, for instance, the healthcare system cost and personal devastation of stroke to an individual who suffers an embolic event due to lack of therapy is great."

Tanzid Shams, MD: "NOACs are game changers for medically compliant patients who do not have to come into the doctor's office over and over to get their INRs checked."

Diana Greene-Chandos, MD: "There is hope in the future for these agents, as there are antidotes for these agents under study."

Michael S. Lloyd, MD: "Due to the relatively short half-life of these new drugs, the presence or the absence of antidotes is not terribly relevant. In other words, by the time it would take to infuse the antidote to the traditional Coumadin or warfarin, the new blood thinner's effect would have already disappeared."

Patrick D. Lyden, MD: "Use them! We have 'antidotes' for very few medications. It's a complete non-issue."

Warfarin Has Its Up Side

Greene-Chandos: "As a neurointensivist, I see many patients with intracranial hemorrhage and the worst are typically from those on anticoagulation. When a patient is on warfarin, we are able to give vitamin K, fresh frozen plasma, and prothrombin complex concentrate (PCC) with a measurable reasonably quick effect by seeing the PT and INR correct. We also can clearly know that the patient can proceed to neurosurgery, if required, in this scenario."

Shams: "While older drugs such as warfarin (Coumadin) are reversible, there is also a downside to the constant monitoring required to keep the levels in a therapeutic range. It's only a matter of time before the antidotes will come down the drug pipeline."

Campbell: "Coumadin has been the gold standard for anticoagulation in atrial fibrillation, DVT, and mechanical heart valves. Now we have alternative therapies that do not require monitoring. In clinical trials these drugs are shown to be safe and effective -- some even show superiority to warfarin."

Greene-Chandos: "In addition, they do not require dietary restrictions as warfarin does, the classic medication used in these clinical scenarios."

Game-Time Decision

Greene-Chandos: "Providers are faced with deciding on a more cumbersome to use, but well-understood medication that has greater bleeding risks but a clear reversal and well-understood protocol, versus the newer agents, that are easy to use, have fewer bleeding risks, but once you bleed reversal is not as well understood, more difficult, and less effective.

"Dabigatran (a direct thrombin inhibitor) can be removed with hemodialysis or use of activated charcoal if a dose was taken recently. However, the process to have a catheter placed for dialysis and then perform it could take too much time, especially when there is bleeding in the brain. Rivaroxaban and apixaban (Factor Xa inhibitors) can be reversed partially with PCC."

Campbell: "Certainly there is risk to the lack of reversal agents -- as physicans, we must consider selecting patients who are most appropriate for alternative anticoagulants -- those with higher risk of falls and bleeding may be more appropriate for Coumadin. Ultimately, like many issues in medicine, the drug selection and treatment course should be based on applying the available data to the clinical situation -- all while considering patient-specific factors."

Friday Feedback is a feature that presents a sampling of opinions solicited by MedPage Today in response to a healthcare issue, clinical controversy, or new finding reported that week. We always welcome new, thoughtful voices. If you'd like to participate in a Friday Feedback issue, reach out to e.chu@medpagetoday.com or @elbertchu.

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